Online Referral Form

We are committed to client outcomes

Please complete and return to our Intake & Assessment Team via the submit button at the end of the form.
One of the team will contact you within 24 hours to proceed with the next step.

    Today's date:Today's date

    Referrer information:

    Please disregard if this is a non medical referral

    Patient information:

    Date of Birth:


    Identifies as

    Refugee status

    Is it safe to send mail to this address?

    Is it safe to leave a voicemail/send an SMS to this number?

    Is it safe to send correspondence to this email address?

    Preferred method of contact

    Does the client have Private Health Insurance?

    Client's Medicare Number


    Ambulance Cover


    What is the Client's current accommodation status?

    (If the client is currently homeless, please consider on-referral at point of assessment)

    Is this accommodation stable and long term?

    Have any risks been identified related to Client's current accommodation arrangements?

    Is the Client a primary caregiver for any dependants?

    In the event that the client undertake and inpatient rehabilitation program are there arrangements for the care of the Clients' dependants?

    Does the Client have any children not currently in their care?

    Is the Client engaged with DHHS/Child Protection?

    Is the Client currently employed?

    Is the Client a Forensic client?

    Is the Client currently on Remand in Custody?

    Does the Client have any interventions in place?

    If yes:

    Does the Client have a regular GP?

    (If not please flag for follow up on admission)

    Is the Client engaged with other services?


    Child Protection



    Financial Services

    Men's behaviour changes services

    Mental health services



    AOD services


    Alcohol and other drug use

    Substance use in the past year

    Usual route of administration

    Has the Client injected in the past 3 months?

    Does the Client have a history of overdose or admission to hospital as a result of substance use?

    Is there evidence of risk behaviour related to the Client's risky (eg. DUI, unsafe injecting, using alone)?

    Is there evidence of harm or potential harm to the client as a result of substance use (eg. interpersonal, financial, legal, mental/physical health)?

    Has the Client been engaged with Detox/Rehab services in the past?

    Is the Client currently prescribed Pharmacotheraphy (Methadone, Buprenorphine, Suboxone)?

    Physical and Mental Health


    Food Intolerances

    Dietary Requirements

    Does the Client have any physical health concerns?

    (document below)


    Chronic Pain



    Liver Disease

    Heart Disease




    Does the Client take any prescribed medication?

    Does the Client have a mental health diagnosis?

    Does the Client have any thoughts of self harm/suicide?

    Has the Client ever self harmed or attempted suicide?

    Has the Client ever been engaged with the CATT team?

    Does the Client have a safety plan?

    Has the Client presented to the Emergency Department or been admitted to hospital in the last 12 months?

    Does the Client have a history of violent or aggressive behaviour towards family, friends, or service providers?

    Does the Client have any immediate concerns for their safety?

    Preferred date of admission:

    Is the Client available at short notice?